Re: Guarino v Good Samaritan Hospital
File #2 121100
Case summary:
The plaintiff was 38-year-old female who presents at eight weeks of pregnancy for an elective D&C. on 6/11/07. She was brought to the operating room and underwent a D&C. At the time of the suction curettage, an inadvertent perforation of the uterus was noted. A laparoscopy was performed and a small fundal perforation was oversewn using a single 0 Dexon suture through and through finding complete reapproximation and hemostatis. The small and large bowel was carefully inspected and found to be without evidence of injury. A surgical report was as follows:
Again the small and large bowel were inspected and found to be completely normal. At the termination of procedure, all counts were correct. No other intraoperative complications. Anesthesia was promptly reversed, and the patient was transported in stable condition. Two days later, patient developed an acute abdomen with peritonitis (intra abdominal infection)
She was brought into the operating room, placed on the operating table in supine position following her transport from the intensive care unit where she had had a Foley catheter placed. Following satisfactory general endotracheal anesthesia and the insertion of an NG tube , the right subclavian line was placed under sterile technique. The patient’s abdomen was than prepped and draped in the usual sterile manner. A midline incision was made below the umbilicus, down towards the pubis with a scalpel. The fascia was opened using the Bovie cautery. Midline was then opened using the Metzenbaum scissors and the peritoneum was grasped with 2 Hemostats and incised with the scalpel. Bile was found within the abdomen. Suction was used to aspirate approximately 3000 cc of bile, but half of it was in the pelvis and the remainder was beneath both diaphragms.
The small bowel was run and approximately 5-to7-mm perforation of the ileum, approximately 1 foot from the ileocecal valve was found. This was repaired with 3-0 chromic through and through sutures followed by 3-0 silk seromuscular sutures. The bowel was run from the ligament of Treitz to the ileocecal valve and no other injury was found. The appendix was scarred down into the right lower quadrant and after it was freed up, an appendectomy was performed by ligating the mesentery of the appendix with 0 chromic ties. The appendix was sent to pathology for examination. The abdomen was at the end, the Jackson Pratt-drain was brought out through a stab wound, which had been used for a laparoscopic procedure in the left lower quadrant.
Patient was seen by cardiology, GI and infectious disease consultants. Her postoperative management included antibiotics as per the Infectious disease service, aggressive IV hydration and nutritional supplementation.
• What evidence of malpractice exists?
Perforating the uterus during D&C is not a departure but a complication. The same goes for a bowel perforation. Failure to diagnose such a complication is a departure. In our case, laparoscopic surgical report reads as follows…
The small and large bowel were carefully inspected and found to be without evidence of injury. This statement was proven to be inaccurate: a small bowel perforation was found at laparotomy.
• What departure exists, if any, from community medical standards?
Failure to diagnose a complication of a D&C (bowel perforation) represents a departure from the community medical standards.
• Is there a causal relationship between the departure and the alleged injury?
Delayed diagnoses of bowel perforation resulted in some of the alleged damages including peritonitis, acute abdomen, bile peritonitis, sepsis and ICU admission. Some of the alleged damages (need for laparoscopy, laparotomy, IV antibiotics, etc.) were due to an expected D&C complications. I have no criticism of good Samaritan staff.
Thank you for asking me to review this case,
Sincerely yours,
B. Petrikovsky MD PhD